Long-Acting Injectables: Should Psychiatry Residents Be Required to Give Them?

Long-acting injectable medications, known in clinical circles as LAIs, occupy a curious position in modern psychiatry. The evidence base behind them is robust: depot preparations of antipsychotics and other psychotropic agents improve adherence, reduce relapse and rehospitalization, and are recommended in major treatment guidelines for psychotic disorders, affective illnesses, autism spectrum disorders, and substance use disorders. Yet a new commentary published in Academic Psychiatry by Tiffany Z. Teng of the University of Illinois at Chicago and Eric C. Zimmerman of West Virginia University’s Rockefeller Neuroscience Institute highlights a striking gap at the heart of psychiatric training: nobody has standardized who actually administers these injections, and whether the physicians who prescribe them should be required to learn to give them during residency.

The authors begin with a deceptively simple question that the primary literature has largely ignored: who administers LAIs? In their experience across multiple institutions, practices vary dramatically. In some settings, injections are delivered exclusively by allied health professionals such as nurses, while physicians confine themselves to the prescription pad. In others, including community mental health centers, street psychiatry teams, assertive community treatment programs, solo private practices, and teaching hospitals where faculty must instruct trainees, the prescribing physician administers the injection directly. This patchwork of practice raises an obvious educational question: if the skill may be needed in practice, shouldn’t residency guarantee exposure to it?

The regulatory landscape offers little clarity. The Accreditation Council for Graduate Medical Education requires that psychiatry residents perform all “medical, diagnostic, and surgical procedures considered essential for the area of practice,” but provides no specific enumeration of which procedures qualify. The result, the authors report based on their own experience and communications with colleagues, is wide divergence among United States programs. At the University of Illinois Chicago, LAI administration is a required learning objective in the postgraduate year three and four, with residents expected to inject patients in clinic. At Northwestern Medicine, by contrast, injections are handled exclusively by nurses and support staff, and residents receive no opportunity to learn the procedure at all. Two prestigious programs in the same city, in other words, produce graduates with fundamentally different procedural skill sets.

The educational argument for requiring LAI training is compelling on its face. Experiential learning, the authors argue, sticks in ways that textbook reading does not. A resident who orders haloperidol decanoate and then draws up the correct volume from a multidose vial will understand dosing more deeply than one who merely reads about it. A resident who examines an injection site reaction and participates in its management gains clinical intuition that a secondhand description from a nurse cannot convey. Procedural competence also deepens prescriber empathy and knowledge, which in turn shapes how confidently physicians discuss these treatments with ambivalent patients.

The public health stakes are considerable, because LAIs are dramatically underutilized. Studies cited in the commentary show that only 19 to 30 percent of patients with schizophrenia are prescribed LAIs, and an analysis of the National Mental Health Services Survey found that only 30 percent of surveyed providers prescribe them at all. A major driver is prescriber knowledge and attitude: many psychiatrists view LAIs as a “last-resort” treatment or assume they are less effective in first-episode psychosis, beliefs contradicted by current evidence. Crucially, greater knowledge about LAIs is associated with more positive attitudes toward them. The implication is that residents who administer LAIs during training may be more likely to prescribe or deliver them afterward, slowly eroding the attitudinal barriers that keep an effective treatment class on the shelf.

Hands-on experience may also improve the therapeutic conversation itself. Initiating an LAI is often a delicate negotiation, since patients frequently have mixed feelings about injections versus oral medication, and some decline them because injections feel controlling or coercive. Notably, psychiatrists cite injection site pain as a reason for reluctance, yet only a minority of patients report it as a barrier, suggesting that unfamiliar prescribers misjudge the patient experience. Research also shows that the way a provider offers an LAI influences whether the patient accepts it. A physician who administers the injection personally may signal genuine faith in the treatment, reinforcing the therapeutic alliance, improving adherence, and ultimately increasing both patient and prescriber satisfaction.

There are career and access arguments as well. Some positions specifically require physicians who can administer LAIs, and graduates with the skill are more competitive for them; learning in residency offers a more structured, supportive environment than picking the technique up in practice. In resource-poor regions without support staff, a psychiatrist who can deliver injections may be the only person able to do so across a large geographic area, making the skill a matter of access, not just convenience. Offering both oral and long-acting formulations, tailored to individual patient factors, the authors contend, simply constitutes higher quality care.

Yet the commentary is careful to present the counterarguments, and they are substantial. Residents themselves often describe administering LAIs as repetitive, comparing it to drawing blood, with educational value that diminishes over years of exposure. Residency already presents an overwhelming range of learning objectives, and adding another risks work compression. The ACGME defines “non-physician obligations” as duties normally performed by nursing, allied health, transport, or clerical staff, and injection administration could plausibly fall under that umbrella, though the definition remains controversial. Burnout looms over the entire debate: up to 75 percent of resident physicians report symptoms of burnout, and the American Medical Association’s top cited stressors include too many administrative tasks and inadequate support staff. Layering a procedural requirement onto that load, critics would argue, only deepens the problem.

Practical infrastructure poses another obstacle. Proper LAI training demands staffing, pharmacy support, clinic space, supplies, scheduling, documentation, and navigation of state and institution-specific policies about whether residents may even perform the task. Many resident clinics, in the authors’ experience, lack key infrastructure or struggle to sustain it over time, and asking trainees to learn injections in an under-resourced clinic risks pushing them outside their comfort zone while degrading the patient experience. There is also a macro-level question: with a projected shortage of between 14,280 and 31,091 psychiatrists in the 2020s, is physician time spent holding a syringe the best allocation of a scarce resource, or should injections remain with allied health professionals?

Teng and Zimmerman come down, on balance, in favor of expanded training. They suggest programs could either mandate LAI training for all residents, maximizing public health benefit at the cost of significant resources, or offer it as an elective, capturing motivated trainees while risking low uptake. Either path requires deliberate support: protected time outside other clinical duties, instruction from qualified experts including pharmacists, nurses, and attending physicians, written reference materials, repeated observed practice with patients from continuity clinics, real-time supervision on request, extended 45-minute appointment slots to avoid work compression, and a clinical experience lasting at least six months to cover initiation, efficacy monitoring, and adverse effect management. The authors frame the debate as emblematic of a broader tension in graduate medical education, balancing educational and public health benefits against resident workload and burnout, and they call for research to characterize the diversity of educational approaches, codify best practices, and quantify the true costs and benefits of psychiatrists administering LAIs during training. Whether residency programs heed the call may shape not just a generation of psychiatrists’ skill sets, but the accessibility of one of psychiatry’s most underused treatments.

Subject of Research: Whether psychiatric residents should be required to learn to administer long-acting injectable medications during training

Article Title: Should Residents Be Required to Administer Long-Acting Injectables?

Article References: Teng, T. Z., & Zimmerman, E. C. (2026). Should Residents Be Required to Administer Long-Acting Injectables?. Academic Psychiatry. https://doi.org/10.1007/s40596-026-02441-6

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02441-6

Keywords: long-acting injectables, psychiatry residency, medical education, antipsychotics, ACGME, resident burnout, schizophrenia, medication adherence, workforce shortage, psychopharmacology, clinical training, patient care